Provider Demographics
NPI:1114266889
Name:AMERICAN CUSTOM COMPOUNDING PHARMACY
Entity type:Organization
Organization Name:AMERICAN CUSTOM COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNDELFINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-366-0022
Mailing Address - Street 1:2607 WALNUT HILL LN
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-5638
Mailing Address - Country:US
Mailing Address - Phone:214-366-0022
Mailing Address - Fax:214-366-0298
Practice Address - Street 1:2607 WALNUT HILL LN
Practice Address - Street 2:SUITE 220
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-5638
Practice Address - Country:US
Practice Address - Phone:214-366-0022
Practice Address - Fax:214-366-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX279763336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy